DCS files reveal little about children's deaths

In one boy's death, only 35 of 637 pages were released

Feb. 10, 2013

On June 12, 2011, a teen under DCS supervision was killed in a rollover crash. With the teen listed as a runaway, DCS records provided don’t indicate what efforts they took to find him in the weeks preceding his death.

Written by

Tony Gonzalez and Brian Haas

The Tennessean

Four cases, three deaths, few answers

In response to a lawsuit by The Tennessean and other media outlets, a Davidson County chancellor released records from four Tennessee Department of Children’s Services investigations for the first time. The following are snippets from investigations of three child deaths and the near death of a fourth.

On June 12, 2011, a teen under DCS supervision was killed in a rollover crash. With the teen listed as a runaway, DCS records provided don’t indicate what efforts they took to find him in the weeks preceding his death.

An 8-year-old boy with severe medical problems was rushed to an emergency room on Nov. 9, 2010. The boy’s family had a history of problems giving him medication and providing a healthy home.

An 11-month-old boy died of unknown causes in a domestic violence shelter on Jan. 11, 2012. Records provided are spotty in showing how thorough DCS workers were in making sure the boy’s siblings were safe after their mother moved out of the shelter.

After an infant died Oct. 31, 2010, medical experts concluded she had been shaken to death. Investigators struggled to get straight answers from the child’s mother and it’s unclear whether they ever interviewed her boyfriend.

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The last days of life of three Tennessee children, the near death of a fourth child and a glimpse into the state child protection agency’s involvement with each of their families were revealed in state records made public last week.

Notes describing the four child welfare investigations, as written by caseworkers with the Department of Children’s Services, describe a baby shaken to death, a rollover SUV crash that killed a foster child, an infant found dead at a domestic violence shelter and the hospitalization of an asthmatic boy.

The 167 redacted pages contain only a limited number of pages from each child’s DCS record and do not reveal many specifics about the state’s dealings with these families. And because the released records were selected by a judge, DCS officials say that judicial action and confidentiality laws stop them from discussing other specifics about the cases and what details were not provided. That makes a full public evaluation of the state’s actions elusive.

DCS said Friday it has provided what Davidson County Chancellor Carol McCoy ordered them to release.

“Nothing more or less,” said Britany Binkowski, DCS assistant general counsel.

After reviewing the files, McCoy ruled the state must provide some child fatality information as required by federal law, including: the circumstance and cause of the death, age and gender of the child, information about pertinent prior state involvement, results of those prior investigations and the state services provided to the family.

But some of that information is not included in the pages provided to The Tennessean.

DCS officials wouldn’t even say if what the judge ordered released was a full account of their full involvement with each family.

That uncertainty may prevent the public from getting a clear picture of whether proper child protection steps were taken, said Bill Grimm, senior attorney at the National Center for Youth Law, which pushed for more child welfare records openness in California.

“It kind of puts you in a difficult place. The agency can say: ‘You don’t have the whole file, so you don’t have the whole picture,’ ” Grimm said.

Already, another group reviewing DCS files has found the level of documentation “inadequate.”

New York-based child advocacy group Children’s Rights, which oversees a federal court settlement ordering DCS to improve its work, is reviewing complete case files that have not been redacted.

“What’s clear, as an overall matter at this point, is that both their process for tracking child deaths and the process for investigating them — both of those — are inadequate and need to be revised,” said Ira Lustbader, attorney and associate director.

The Tennessean provided written questions to DCS about specifics in the four cases. Spokeswoman Molly Sudderth said answers may need to come from regional staff and that staff attorneys would need to decide whether answers could be provided without breaching confidentiality.

From what limited records were provided, four narratives emerge.

The 16-year-old

DCS investigators had not seen the 16-year-old boy for two months after they say, in records, he “apparently” ran away from home in April 2011. They found him in the morgue.

There’s no explanation in the records about why the boy had been in DCS custody for at least a year. Nor do they indicate whether DCS tried to find him when he ran away. The department provided 35 pages from the teen’s 637-page file.

The boy’s mother had died and his father was in jail.

Then on June 12, 2011, the teen and six others were in his uncle’s SUV when the tire blew and he was ejected from the vehicle. The teen wasn’t wearing a seat belt.

His uncle survived, and investigators later said he had drugs in his system including marijuana, anti-anxiety pills and muscle relaxers.

According to a DCS investigator’s summary, it took two months to get a copy of the police report and eight months for the uncle’s blood test results. The DCS file indicates prosecutors planned to charge the uncle with vehicular homicide.

An interview with an unidentified person two months after the teen’s death indicates the boy shouldn’t have been hard to find while a runaway. The woman said she knew he stayed with certain family members at one point.

The boy’s grandmother complained she too knew where he was at times but never could get any help.

“Whenever she got a lead about (the victim’s) whereabouts, she would always call the authorities,” the DCS investigator wrote. “But … they would never go out when she called.”

The DCS file does not indicate which authorities the grandmother tried to call.

The 11-month-old

DCS had been monitoring a baby and his siblings for about six months when the baby died in a domestic violence shelter Jan. 11, 2012.

The records — just 42 of 169 pages from the file — indicate the agency got involved in July 2011 when allegations surfaced that the children were exposed to drugs.

Sometime in early December, the mother fled to a domestic violence shelter.

On Dec. 6, 2011, DCS was notified of physical abuse to the mother and the 3-year-old boy. DCS learned that on Nov. 22, 2011, the infant’s brother suffered burns to his leg and foot after their father pushed him into a heater.

DCS visited with the mother on Dec. 12 in the shelter. While talking to the mother, DCS learned the 11-month-old baby, a 2-year-old sister and 3-year-old brother were present when their father held a knife to their mother’s throat. It is unclear when that happened.

DCS talked with her about housing, counseling and even offered to provide transportation to services.

On Dec. 29, 2011, the baby was diagnosed with bacterial pneumonia.

The records do not reveal whether DCS knew the infant had fallen ill. Nor do they indicate whether it knew that the mother failed to return to the doctor within three days of the diagnosis, as ordered by the hospital.

Less than two weeks later, the woman found her baby cold to the touch and discolored in his bed at the shelter.

The baby was rushed to an emergency room, but doctors couldn’t revive him.

The case, now elevated to a fatality investigation, prompted a DCS investigator to pull medical records and interview relatives and shelter workers. Law enforcement investigated the death, but an autopsy was inconclusive.

“There is no evidence that the child’s death is due to anything other than natural causes,” investigators concluded.

DCS workers’ follow-up after the death is unclear. The records released indicate that the mother moved out of state and was last visited by a Kentucky child welfare worker on Jan. 19, 2012. A month later, a shelter worker told DCS the mother had “returned to her abuser.”

The records don’t show any attempts to reach the mother until four months later when DCS called the woman and she told the agency that she was living with her parents.

The worker closed the case after completing a safety assessment to determine whether children should be left in a home or taken into custody.

“Child Protective Services Assessor completed the closing (the assessment)” the worker wrote, “But has not seen the children.”

The 9-month-old

On Oct. 29, 2010, the 9-month-old girl was rushed to the emergency room. No one could get a good answer from the mother about why her baby had bruises, wounds to her head and bleeding in her eyes and brain.

Her mother told hospital workers she might have fallen off the couch, but DCS records note hospital personnel were skeptical and called DCS.

In the 48 pages released from the 143-page file, DCS notes this was the agency’s first involvement with the family.

The day after the baby was rushed to the hospital, the state placed the infant’s 2-year-old sister, also bruised, into state custody.

“The staff said that the bleeding could only come from trauma to her head,” the DCS report said. The child died on Oct. 31, 2010. An autopsy received months later confirmed the infant died from homicide. A medical expert said the child probably was shaken violently.

In the first two days of the investigation, the DCS case manager heard conflicting stories from the mother and grandmother, both of whom had cared for the infant in the days before she was injured.

But where the mother’s boyfriend went, the DCS investigator did not know. The records note DCS wanted to question him.

The files reference a detective being involved in the case.

The 8-year-old

The boy had severe asthma, but everyone at his home still smoked. His medication went missing, and an assistant principal had to drive to the 8-year-old boy’s home to get the nebulizer his parents refused to take to the school.

On Nov. 9, 2010, the boy was rushed to the emergency room after passing out in school. He had a history of seizures and blackouts, in addition to numerous other medical problems. He survived.

DCS was called. The agency was familiar with the family because it had been involved with them in April 2009.

But records provide few details about the prior case. The 38 pages released from the 315-page file noted there had been allegations of environmental neglect and possible drug use, but the DCS file shows a caseworker determined “no services needed.”

When a caseworker began to work with the family for the second time, after the boy’s blackout, records show the boy’s parents claimed they were being harassed, at one point telling the investigator they were moving and wouldn’t provide their new address.

The case manager suspected drugs were being abused in the home. The file notes the mother looks like she has used methamphetamines.

The records show the DCS investigator pushed the parents to be more responsible about the boy’s medications, and made the district attorney aware of the case.